Towards Safer Radiotherapy

Appendix 6.1. Care delivery problem
Geographical miss, set-up to left instead of right of reference tattoo by 1.2 cm for 1 #, detected by
off-line review of Day 1 verification images
70
Patient
New patient, anxious, full
bladder, CT planned, with
reference tattoos.
Task
Care for patient. Interpret and
apply set-up instructions, deliver
treatment and take Day 1
verification images.
Environment
Appropriate staffing and skill mix.
Full workload. Staff were
conscious that it would cause
scheduling problems later if the
patient had to get off the bed,
empty bladder, re-fill and come
back into the room.
Some of the set-up instructions
were entered into the R&V free
text box but not shifts so only
visible to one operator. Couch
parameters to be acquired on Day
1. Room lights lowered for set-up,
written note difficult to see.
Individual
Two competent operators
involved in treatment set-up,
experienced in the technique
which was performed about 30
times per day.
Team
More experienced operator
reassuring patient, also reading
instructions from treatment plan
to colleague. Both staff aware of
patient discomfort and need for
completing treatment as soon as
possible. Machine setting checks
carried out before leaving the
room. Full checks set out in
procedure not completed, which
included checking shifts from
reference tattoos.
Very familiar with working
together, no record of making
errors.
Management
Data entry procedure in place but
did not stipulate which
information other than machine
settings should be entered.
Checking procedure in place, not
followed. Perhaps not designed
on risk basis because it repeated
the R&V data entry checks but
did not assess which other factors
were higher risk and concentrate
on those.
Verification procedure in place,
followed and error detected.
Towards Safer Radiotherapy